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Pregnancy following an interilio-abdominal amputation
PREGENANCYFOLLOWING AN INTERILIO-ABDOMINAL AMPUTATION (Sacroiliac Disarticulation or Hemipelvectomy) HOWARD L. WILCOX, M.D., New YORK, N. I’. (From
the
Department
of
Obstetrics the
and Gynecology, Gor7a~TE Univrrsity New York Hospital)
Medical
College
ad
NLY one other case of pregnancy following amputation through the sacroiliac joint has been noted in the literature. That case is reported by Judin,i a Russian surgeon. He 0 did a radical amputation because his patient had a chondrosarcoma involving the upper third of the right thigh and the right inguinal region. Approximately five months after the operation she became pregnant. At term, the patient was admitted prior to the onset of labor so that a cesarean section could be done if necessary. However, she spontaneously delivered a 4,200 gram infant after one-half hour of labor. (That was her ninth baby.) When the patient was heard from one year after delivery, she was in good condition and had just stopped nursing her baby. According to Pack and Ehrlich,z only one hundred thirty-two cases of amputation through the sacroiliac joint have been reported in the literature in the past fifty years. Six more cases were reported by Pack and Ehrlich. Thus, there is now a total of one hundred t,hirty-eight such cases. The case now being reported was presented, prior to pregnancy, in the hemipelvectomy series by Dr. Pack2 (Case 4).
CaseBeport The patient was a 24.year-old white primigravida. She presented herself in our oh stetric clinic with a letter from the Memorial Hospital where the hemipelvectomy had been done. This revealed that on June 15, 1945, a left sacroiliac disarticulation had been carried out for a malignant neurofibroma of the von Recklinghausen type. It had involved the sciatic nerve and its branches and extended into the muscles of the thigh and buttock. The oh turator foramen had been perforated and the pelvic parietes likewise were involved. One yeai after her operation the patient married. Her last menstrual period was on Aug. 2, 1946. Her expected date of confinement was computed to be May 9, 1947. When the patient war first seen in the obstetric clinic, the general physical examination was essentially unremarkable except for the sacroiliac amputation. Her serology was negative and she was found to be Rh negative. Repeated transfusions had been given to the patient during and following the operation. On closer examination of the operative site, some tenderness was noted and the labia on the left were edematous. Rectal examination revealed a mass extrinsic to thr bowel which caused a partial occlusion of the rectum. In January of 1947 it was apparent t.hat this mass was enlarging. Therefore, the patient had an aspiration biopsy done at the Memorial Hospital which revealed a neurosarcoma, considered to be recurrent in origin. After careful evaluation, it was felt that the prognosis of the patient was hopeless, and therefore the pregnancy should be allowed to continue, with the hope of getting a live baby. Pain throughout the surgical stump, lower abdomen, and back became quite constant and annoying. Sedatives and analgesics were administered, and it was planned to give palliative x-ray therapy after delivery of the infant. On March 11, 1947, the patient was admitted to the obstetric service with the signs of early premature labor. The pain in the stump had become excruciating in nature. There was some bowel distention associated with nausea and vomiting. This was controlled with supportive measures. The uterine contractions were stopped with the use of morphine. Two days later, vaginal examination revealed the presence of marked edema of the left 1068
Volume 55 Number 6
PREGNANCY
FOLLOWING .
1069
AMPUTATION
Fig. l.- Lateral view of patient revealing surgical absence of the left leg. The left side of the pelvis (the bony wall of which was removed) is now replaced by tumor mass. Note edema and discoloration of the overlying skin and the marked edema of the left labia.
Fig.
2.-X-ray
of the pelvis reveals mass on left side
absence extending
of the bony structures over to the midline
on the left. of the pelvis.
Note
soft
tissue
1070
WILCOX
labia. The obstetric conjugate was nnrpii., There was some relaxation of the I-aginal canal. X-ray of this :br(‘il r,*x-e:iIu’~’ On the left side, a hard xpheriral n~ass extended to thca midline. a large, soft tissue mass that extended to the sacrum with evidence of bony erosion. Anorexia, nausea, and vomiting develop~~~.l. The clinical course was rapidly downhill. Intravenous fluids, transfusions, &\ lowgrade tPmp“l’“and sedatives were administered. ture developed. It was apparent that the patient would not live to go to term. The fetus was estimated to be about 2,200 to 2,300 grams. Since thr, patient was Rh negative, lher blood was tested for antibodies; she was found to have a weak blocking antibody titc’r of 1 :Z and 1:4. On March 20, a classical cesarean scsc+ion was carried out in an attempt to gel AY 2,500 gram male infant was bort1 a living baby prior to the certain exitus of the patient. and appeared to be in good condition. A specimen of cord blood revealed the in fan1 to Ire, R.11 negative. Unfortunately, the baby did not do wrll during the next few days. Yarke(l edema and jaundice developed and, fifty-eight hours after delivery, l,he infant expired. .\ ,I topsy examination revealed the baby to havtx atelectasis with marked c~len~ an11 ,jaundi<~~~. The mother was given supportive measures folloffing the cesarean s;(‘(*i ion. This COW sisted of multiple transfusions of whole blood, infusions of plasma, glucosr, and I-itamin.-. Progressive weakness, edema, pleural effusion and pneumonia developed. On April II, 1917. the patient expired. The significant autopsy findings revealed the presence of multiple neurogenic tibromata The left femoral and sciatic nerves, together with neurogenic sarcoma of the left buttock. with most other nerves distal to the intervertebral foramina in this region, were irregularly and several times enlarged by firm gray-white tumor tissue. Densely adherent to thwf~ ncnw. extending laterally into the left buttock and medially invading the sacrum was a 20 by 15 11. 1.5 cm. firm gray-white mass with small central areas of t~cn~orrl~age and ne(*rosis, Man: nerves throughout the body, including both vagi, phrenirs, and the right femoral and sciatirs nerves, were greatly (up to about eight times normal size), but variably, often locally, enlarged. Metastatic sarcoma was noted by the invasion medially into the sacrum. There was also a single (1 by 0.5 cm.), gray-yellow, firm mrtastatic tumor nodule beneath the pleura of the upper lobe of the left lung. Together the lungs weighed 1,300 grams and were markedly hyperemic and edematous with large firm areas of consolidation in all lobes, l’hrr(~ was a firm red infarct, measuring 4 cm. across, in the lower lobe of the left lung, with :I medium-sized artery occluded by a firm grayish red thrombus. Staph>-lococcus :IIII’CLII* hemolyticus and a pneumococcus, unclassified, were grown from the lungs post mortem.
References 1. Judin, 2, Pack,
Sergey George
S. : Surg., Gynec. T., and Ehrlich,
& Obst. 43: 668, 1926. Harry E.: Ann. Surg.
123:
965,
1946;
124:
3, 1946.
the
Department
of
Obstetrics the
and Gynecology, Gor7a~TE Univrrsity New York Hospital)
Medical
College
ad
NLY one other case of pregnancy following amputation through the sacroiliac joint has been noted in the literature. That case is reported by Judin,i a Russian surgeon. He 0 did a radical amputation because his patient had a chondrosarcoma involving the upper third of the right thigh and the right inguinal region. Approximately five months after the operation she became pregnant. At term, the patient was admitted prior to the onset of labor so that a cesarean section could be done if necessary. However, she spontaneously delivered a 4,200 gram infant after one-half hour of labor. (That was her ninth baby.) When the patient was heard from one year after delivery, she was in good condition and had just stopped nursing her baby. According to Pack and Ehrlich,z only one hundred thirty-two cases of amputation through the sacroiliac joint have been reported in the literature in the past fifty years. Six more cases were reported by Pack and Ehrlich. Thus, there is now a total of one hundred t,hirty-eight such cases. The case now being reported was presented, prior to pregnancy, in the hemipelvectomy series by Dr. Pack2 (Case 4).
CaseBeport The patient was a 24.year-old white primigravida. She presented herself in our oh stetric clinic with a letter from the Memorial Hospital where the hemipelvectomy had been done. This revealed that on June 15, 1945, a left sacroiliac disarticulation had been carried out for a malignant neurofibroma of the von Recklinghausen type. It had involved the sciatic nerve and its branches and extended into the muscles of the thigh and buttock. The oh turator foramen had been perforated and the pelvic parietes likewise were involved. One yeai after her operation the patient married. Her last menstrual period was on Aug. 2, 1946. Her expected date of confinement was computed to be May 9, 1947. When the patient war first seen in the obstetric clinic, the general physical examination was essentially unremarkable except for the sacroiliac amputation. Her serology was negative and she was found to be Rh negative. Repeated transfusions had been given to the patient during and following the operation. On closer examination of the operative site, some tenderness was noted and the labia on the left were edematous. Rectal examination revealed a mass extrinsic to thr bowel which caused a partial occlusion of the rectum. In January of 1947 it was apparent t.hat this mass was enlarging. Therefore, the patient had an aspiration biopsy done at the Memorial Hospital which revealed a neurosarcoma, considered to be recurrent in origin. After careful evaluation, it was felt that the prognosis of the patient was hopeless, and therefore the pregnancy should be allowed to continue, with the hope of getting a live baby. Pain throughout the surgical stump, lower abdomen, and back became quite constant and annoying. Sedatives and analgesics were administered, and it was planned to give palliative x-ray therapy after delivery of the infant. On March 11, 1947, the patient was admitted to the obstetric service with the signs of early premature labor. The pain in the stump had become excruciating in nature. There was some bowel distention associated with nausea and vomiting. This was controlled with supportive measures. The uterine contractions were stopped with the use of morphine. Two days later, vaginal examination revealed the presence of marked edema of the left 1068
Volume 55 Number 6
PREGNANCY
FOLLOWING .
1069
AMPUTATION
Fig. l.- Lateral view of patient revealing surgical absence of the left leg. The left side of the pelvis (the bony wall of which was removed) is now replaced by tumor mass. Note edema and discoloration of the overlying skin and the marked edema of the left labia.
Fig.
2.-X-ray
of the pelvis reveals mass on left side
absence extending
of the bony structures over to the midline
on the left. of the pelvis.
Note
soft
tissue
1070
WILCOX
labia. The obstetric conjugate was nnrpii., There was some relaxation of the I-aginal canal. X-ray of this :br(‘il r,*x-e:iIu’~’ On the left side, a hard xpheriral n~ass extended to thca midline. a large, soft tissue mass that extended to the sacrum with evidence of bony erosion. Anorexia, nausea, and vomiting develop~~~.l. The clinical course was rapidly downhill. Intravenous fluids, transfusions, &\ lowgrade tPmp“l’“and sedatives were administered. ture developed. It was apparent that the patient would not live to go to term. The fetus was estimated to be about 2,200 to 2,300 grams. Since thr, patient was Rh negative, lher blood was tested for antibodies; she was found to have a weak blocking antibody titc’r of 1 :Z and 1:4. On March 20, a classical cesarean scsc+ion was carried out in an attempt to gel AY 2,500 gram male infant was bort1 a living baby prior to the certain exitus of the patient. and appeared to be in good condition. A specimen of cord blood revealed the in fan1 to Ire, R.11 negative. Unfortunately, the baby did not do wrll during the next few days. Yarke(l edema and jaundice developed and, fifty-eight hours after delivery, l,he infant expired. .\ ,I topsy examination revealed the baby to havtx atelectasis with marked c~len~ an11 ,jaundi<~~~. The mother was given supportive measures folloffing the cesarean s;(‘(*i ion. This COW sisted of multiple transfusions of whole blood, infusions of plasma, glucosr, and I-itamin.-. Progressive weakness, edema, pleural effusion and pneumonia developed. On April II, 1917. the patient expired. The significant autopsy findings revealed the presence of multiple neurogenic tibromata The left femoral and sciatic nerves, together with neurogenic sarcoma of the left buttock. with most other nerves distal to the intervertebral foramina in this region, were irregularly and several times enlarged by firm gray-white tumor tissue. Densely adherent to thwf~ ncnw. extending laterally into the left buttock and medially invading the sacrum was a 20 by 15 11. 1.5 cm. firm gray-white mass with small central areas of t~cn~orrl~age and ne(*rosis, Man: nerves throughout the body, including both vagi, phrenirs, and the right femoral and sciatirs nerves, were greatly (up to about eight times normal size), but variably, often locally, enlarged. Metastatic sarcoma was noted by the invasion medially into the sacrum. There was also a single (1 by 0.5 cm.), gray-yellow, firm mrtastatic tumor nodule beneath the pleura of the upper lobe of the left lung. Together the lungs weighed 1,300 grams and were markedly hyperemic and edematous with large firm areas of consolidation in all lobes, l’hrr(~ was a firm red infarct, measuring 4 cm. across, in the lower lobe of the left lung, with :I medium-sized artery occluded by a firm grayish red thrombus. Staph>-lococcus :IIII’CLII* hemolyticus and a pneumococcus, unclassified, were grown from the lungs post mortem.
References 1. Judin, 2, Pack,
Sergey George
S. : Surg., Gynec. T., and Ehrlich,
& Obst. 43: 668, 1926. Harry E.: Ann. Surg.
123:
965,
1946;
124:
3, 1946.